There are a number of different meanings for the word impotence or erectile dysfunction. For the purpose of this discussion, impotence shall be defined as "the inability to have or sustain and erection long enough to have meaningful (within reason) sexual intercourse."  Impotence is often primarily a vascular problem resulting in a loss of elasticity in the arteries - a condition causing poor circulation and impairing blood flow. Healthy circulation and blood flow are necessary to maintain an erection.  There are several forms of impotence:

• Organic erectile dysfunction:  This tends to occur gradually until the male never has night time or early morning erections.
• Psychogenic impotence:  This tends to occur suddenly but the male continues to have spontaneous erections at night or in the early morning (often associated with a full bladder).
• Partial erectile dysfunction:  Where the male will develop an erection but it either goes away prior to intercourse or is so flaccid that successful intercourse does not occur

Facts

• 50% of men in their 80s and 90s experience night time and morning erections
• 50% of men age 70 are still sexually active
• 51% of normal, healthy males age 40 to 70 experience some degree of impotence - defined as a persistent problem attaining and maintaining an erection rigid enough for sexual intercourse.
• Approximately 40% of men in their 40s, 50s and 60s will experience some degree of lethargy, depression, increased irritability, mood swings, and difficulty in attaining and sustaining erections that characterize male menopause.
• Two-thirds of 40 year old men diagnosed with heart disease exhibited at least moderate impotence.
• Tissue samples from patients with chronic alcoholism (10 or 15 years of heavy drinking) demonstrate that prolonged alcohol abuse causes irreversible damage to the nerves inside the penis.

Diagnosis

The diagnosis of largely based on a careful medical and psychological history.  At times, measurement devices can be placed on the penis to determine if spontaneous night time erections occur and to compare the blood pressure within the penis with the blood pressure in an arm.  Common causes for impotence need to be sought out including:

Medical Problems:

• Diabetes
• Vascular disease
• Low testosterone levels
• Other endocrine disorders such as an underactive thyroid

Poor habits

• excessive alcohol use
• smoking (causes microvascular disease)
• obesity
• lack of exercise

Medications

• Anti-hypertensive medications such as diuretics and beta blockers
• Anti-depressants-- both tricyclic antidepressants such as Elavil (imipramine) and the new SSRIs, particularly Prozac and Zoloft
• Tranquilizers
• Anti-histamines
• Asthma medications such as ephedrine
• Digestive medications such as Tagamet

Psychological problems

• Stress
• Depression
• Fatigue from overwork
• Marital Problems

History of Vasectomy

Treatment

The treatment for impotence is usually more complicated than one single approach.  First, a distinction needs to be made between men with organic erectile dysfunction and those with so-called "psychogenic" impotence.

Men who never experience an erection because of vascular disease should be referred to a urological specialist.  Caution should be taken with the use of medications which dilate blood vessels, such as Viagra, because men with advanced vascular disease in the penis probably have a similar condition in the heart and other tissues and are at great risk of major complications from drug use (such as a heart attack or stroke).   Men who use nitroglycerin type medications for angina should be especially cautious and should consult with their cardiologists before strenuous sexual activity or the use of any sexual enhancing drug.

With respect to so-called "psychogenic impotence", it is rarely purely psychological.   Aging, hormones and overall physical and mental well-being all factor into the condition. The psychological problems of the male mid-life crisis along with depression are also major contributing factors.  Many doctors agree that if a man has an understanding partner, monitors his medications, alcohol intake and eating habits, stops smoking, and improves the health of his vascular system through aerobic workouts, he will almost certainly see an improvement in his overall wellness and sexual potency.

In cases where men have a depressed serum testosterone level (only 8-16% of men with impotence have low testosterone levels), specialized treatment is needed.  New findings from English studies suggest that men can improve sexual function, muscle strength, and general well-being if they are treated with supplements to bring their testosterone levels into a high - normal range. Estrogen Replacement Therapy (ERT) is now almost universally accepted by physicians as the future of preventative medicine for women in the second half of life.   Will Testosterone Replacement Therapy be far behind?

Currently there are several methods of testosterone supplementation including shots, implants and a transdermal patch. If injections are indicated, they should be administered at least every two weeks to ensure that testosterone blood levels are constant throughout the treatment. Another option is testosterone implants which are surgically placed behind the gluteus muscle in order to release a steady level of testosterone into the bloodstream. An even newer treatment is the transdermal patch (Testoderm). This patch is placed on the scrotum. Unfortunately, the patient must shave the area where the patch will be affixed and apply a new patch daily. Another transdermal patch (Androderm) has the advantage of being placed on the skin of the abdomen or back.  All of these treatments boost testosterone levels in the blood to therapeutic levels, and the patient must determine with the help of his doctor which is the best for him.  Unfortunately, testosterone is not particularly effective in treating erectile dysfunction (impotence) except in instances of markedly depressed testosterone levels.  Even eunuchs from ancient times who were castrated after puberty were capable of maintaining erections.   It was a custom in ancient Rome that women would use more potent eunuchs for pleasure without the risk of procreation (Carruthers, 1997).

In the past,  effective treatments for impotence included vacuum pumps, injections of medications (Papaverine, Caverjet) into the base of the penis, and prosthetic implants.  A number of newer medications have become available in the last several years including:

Alprostadil (Muse)-- a pellet placed within the urethra (the passage in the penis where urine comes out)

Sildenafil (Viagra)--an oral tablet which doses not cause an erection but enhances one.   This should be used very cautiously in men with vascular disease.

New oral compounds in late stage clinical development include apomorphine and phentolamine (Vasomax).  There are also topical creams, sublingual tablets, other intraurethral tablets, and injections being studied at this time.